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Application For Qualification Of Securities Previously Sold In Ohio 39 - Ohio
| Application For Qualification Of Securities Previously Sold In Ohio Form. This is a Ohio form and can be used in Securities Blue Sky Secretary Of State . |
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STATE OF OHIO Telephone File Number Department of Commerce (614) 644-7381 Division of Securities 77 South High Street, Columbus, Ohio 43215-6131 Form 39 Application for Qualification of Securities Previously Sold in Ohio With out Compliance With Section 1707.01 to 1707.45, Inclusive, Revised Code of Ohio (Section 1707.39, Revised Code) Registrant Must Not fill In. Checked Division Record -- Date By Notation Filing Fee ($100.00) Received Qualification Fee Received Record Made Division Order (Application Refused/Granted) Examination Requested Prior Registration (Registrant Must Not Fill In. (Section) (File) (Date) (Amount) (Description) (Price) (Section) (File) (Date) (Amount) (Description) (Price) (Section) (File) (Date) (Amount) (Description) (Price) (Section) (File) (Date) (Amount) (Description) (Price) This Registration (Registrant Must Not Fill In. (Section) (File) (Date) (Amount) (Description) (Price) (Section) (File) (Date) (Amount) (Description) (Price) 1. Issuers Name 2. Issuers Address 3. The issuer is: (State whether individual, partnership, corporation, sy ndicate, association, etc.) 4. Date of incorporation or organization under the laws of . State 5. The charter or articles of association of the issuer now authorize the f ollowing securities: Amount Description COM 4542 (Rev. 3/05) American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 26. The issuer now has the following securities sold or subscribed: (Inclu de all classes of stock, bonds, debentures, promissory notes, or other securities.) Amount Description Amount Description 7. The Securities now sought to be qualified, which have been sold or subsc ribed in OHIO without compliance with Section 1707.01 to 1707.45, inclusive R.C., are: A. Type of security to be qualified: (e.g. common stock, limited partners hip units, etc.) B. Sales Price: (if there were differing prices, attach a separate sheet listing date of sale, number of units, and sales price for each sale.) C. Earliest Date of Sale: (List the earliest date at which (i) a subscr iption agreement was signed by any purchaser of securities to qualified or (ii) the date at which the pur chaser tendered funds or things of value for the securities to be qualified.) D. Latest Date of Sale: (List the latest date at which (i) either a sub scription agreement was signed by any purchaser of securities to be qualified or (ii) the date at which the purchaser tendered funds or things of value for the securities to be qualified.) E. Amount of Securities to be qualified in units. 8. The following are the names and business addresses of all directors, off icers, promoters, trustees, partners, or other managers of the issuer: Name Business Address City State Zip9. Identify who sold the securities. If other than the issuer, indicate na me, address, and Ohio broker-dealer salesman number for all concerned. Name Business Address City State Zip10. Indicate amount of commission (dollar amount and percentage) or other remuneration paid to all individuals connected with this sale: 11. Submitted herewith is: (Total fees) (Check No.) Payers Federal Tax Identification Number (Needed in case of refund of Qualification Fee) Two fees are required as follows: Filing Fee .............................................$100.00 Qualification Fee (minimum)................$100.00 (1/5 of 1% of the aggregate price; up to a minimum fee of $2,000.00) 12. Attached hereto and made part hereof are the following exhibits: A. A receipted copy of the issuers Articles of Incorporation, and also a copy of By-Laws, and Regulations, if the issuer is a corporation, or a copy of instruments governing the operatio n of the issuer and rights of participants if the issuer is a partnership, trust, syndicate or association. American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3 B. A schedule showing (1) the number of units of each type of the issuer s securities (e.g. common stock, bonds, preferred stock, etc.) held by each director, promoter, trustee, partne r, or other executive manager or officer (2) a detailed description of what was paid to the issuer in cash, rea l estate, patents, services or other items of value in the purchase of such securities by each of such persons. C. A schedule showing (1) the names and addresses of all persons who purc hased securities sold in violation of Section 1707.01 to 1707.45, inclusive, R.C., now sought to be qualified, and (2) a detailed description of what was paid to the issuer in cash, real estate, patents, services or other items of value in the purchase of such security by each of such person. D. A copy of each subscription agreement signed by the purchasers. E. Copies of all contracts or other instruments pertaining to the sale of i ssuers securities and used in connection with such sale. F. Copies of any letters, literature, or prospectuses used in connection wi th the sale of issuers securities. G. Provide balance sheet and income statements for the prior three years fo r the entity whose securities are to be qualified. Supply either: (1) Audited statements with auditors letter, or (2) An affidavit of the Chief Executive Officer of the entity whose securiti es are to be qualified hereunder. Affidavit shall be made under oath or affirmation of the officer attesting that, to his best knowledge and belief, the financial statemen t and supporting schedules are true and correct. (Name of Issuer or Applicant) X Signed By: (Officer, Partner, Dealer or Applicant) COUNTY OF STATE OF being first duly sworn, deposes and says that he is that he (Officer, Partner, Dealer or Applicant)has read the foregoing applications; that he has knowledge of the facts, and that the facts stated are true, as he verily believes. X Signed By: (Officer, Partner, Dealer or Applicant) Sworn to and subscribed before me this day of (Month, Year) Notary Public County Name, address, and telephone number or correspondence to whom communicat ions regarding this application may be sent: The Statement of Non-Prejudice to be signed by the original purchasers w ill be forwarded upon receipt of this application with appropriate fees attache d. Address all communications and make all checks payable to: Ohio Division of Securities, 77 South High Street, Columbus, Ohio 43215 -6131 614-644-7381 American LegalNet, Inc. www.USCourtForms.com
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